The Start Healthy Feeding Guidelines for Infants and Toddlers: An Evidence-Based Approach

Synopsis — Recently, the American Dietetic Association (ADA) partnered with Gerber Products Company to collaborate on the "Start Healthy, Stay Healthy™" research and education initiative. A key component of that initiative is the Start Healthy Feeding Guidelines for Infants and Toddlers, a concise, up-to-date, authoritative reference for infant and toddler feeding.

Three different methods were used to compile the data necessary to develop the Start Healthy Feeding Guidelines, including: evaluating existing recommendations and guidelines from recognized organizations; using the ADA's evidence-based approach to analyze the literature; and conducting detailed analysis of the nutrient content of infants' and toddlers' diets compared to Dietary Reference Intakes (DRIs). This article explores the detailed process that led to the Start Healthy Expert Panel's conclusions and recommendations.

From even before birth until age two, what an infant or toddler eats may shape both short and long-term eating habits,1-5 and significantly influence his or her immediate and future health.6-8 The vast majority of parents are eager to feed their children the foods needed for healthy growth and development, and frequently look to a pediatric health professional for guidance about appropriate feeding practices. Yet, with the seemingly daily influx of pediatric health and nutrition research and information, pediatric professionals may find themselves in need of a reliable, up-to-date, concise and authoritative reference for providing dietary and feeding guidance to parents of infants and young children.

The American Dietetic Association (ADA) partnered with the Gerber Products Company to establish just such a reference, called the Start Healthy Feeding Guidelines for Infants and Toddlers. A panel of experts created these Guidelines using a three-part approach - the cornerstone of which was an ADA evidence-based literature review. Their goal was to integrate and update current infant and toddler feeding guidelines, and develop practical answers to parents' most common questions about feeding infants and toddlers. The related consumer-focused guidance is being developed and is anticipated to be released within the next year.

The ADA Evidence-Based Approach
As with evidence-based medicine, the two guiding principles of the ADA evidence-based approach are: 1) the establishment of a hierarchy of evidence that supports a recommendation, and 2) the recognition that clinicians and experts need to factor in a patient's values and preferences, as well as the values of society, when providing guidance about feeding infants and young children.9

The Start Healthy Expert Panel utilized the same seven-step ADA evidence-based approach used to prepare clinical guidelines, which include:

Identifying a specific problem or area of uncertainty (in this project, areas for practical feeding advice);

Formulating the problem as a research question;

Developing a systematic search strategy and finding evidence;

Selecting the relevant evidence;

Evaluating and grading the evidence;

Forming recommendations or making decisions based on the best available evidence;

Summarizing and disseminating the findings.10

Most health care providers are familiar with the formal evidence analysis grading process used to create medical guidelines. The major difference in the ADA evidence-based approach and the well-known and most commonly used Centre for Evidence-Based Medicine (CEBM) method is the way in which research is classified, graded, and the evidence summarized (Steps 5 and 6). In the ADA method, evidence is classified as A (randomized controlled trials), B (cohort study), C (nonrandomized trial with concurrent or historical controls, case-control study, study of sensitivity and specificity of diagnostic test, or population-based descriptive study), D (cross-sectional study, case series, or case report), M (meta-analysis, systematic review, decision analysis, cost-benefit analysis, cost-effectiveness study), N (narrative review, consensus statement, consensus report), and X (expert opinion).

For purposes of an ADA evidence-based approach, review articles, consensus documents and statements of expert opinion are also classified as "evidence" and included in the evidence summary. The terms used for grading the evidence are reflected by Roman numerals I through IV as shown in Table 1. Conclusion statements with a Grade III or Grade IV indicate that the existing research base is limited and the related questions cannot be answered with a high degree of certainty. In particular those supported by Grade IV, expert opinion, are clear opportunities for pediatric researchers to address questions that have not previously been definitively answered.

Based on the best evidence, the Start Healthy Expert Panel developed the Start HealthyFeeding Guidelines recommendations, and the process used was summarized and published as "Development of the Start Healthy Feeding Guidelines for Infants and Toddlers" in the March 2004 issue of the Journal of the American Dietetic Association (JADA).11 The authors of the JADA article, which represent various areas of expertise, made up the core team responsible for conducting background work for the Expert Panel. These core team members were trained by the ADA in order to correctly utilize the ADA's tools (such as worksheets and evidence summaries), as well as their approach to evidence-based analysis. The foundation for the Start Healthy Feeding Guidelines was laid during meetings and conference calls between the core team and the Expert Panel, as they worked together to develop appropriate topic areas, discuss the evidence, and analyze the findings.

Methods Used to Create the Guidelines
In total, three different methods were used to compile the data necessary to develop the Start Healthy Feeding Guidelines: 1) evaluate existing recommendations and guidelines from recognized organizations, 2) evaluate the feeding and nutrition literature using the ADA evidence-based approach, and 3) conduct a detailed analysis of the nutrient content of infants' and toddlers' diets compared to Dietary Reference Intakes (DRIs). The preferred method was to use the ADA evidence-based approach. This systematic review of the research benefits from the clinical expertise of individual practitioners combined with the best clinical evidence for the benefit of patients.

Evaluate Existing Recommendations and Guidelines
In order to develop the Start Healthy Feeding Guidelines, the Expert Panel first identified specific areas where guidance for feeding infants and toddlers was needed. Areas to be evaluated for inclusion in the Guidelines were selected by the Panel based on the belief that they would be practical and useful, and that it was possible to create scientifically sound advice. Recommendations from academic and professional organizations, such as the American Academy of Pediatrics (AAP) and the ADA, and government agencies, including the Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO), were used as a starting point to determine what feeding guidance already existed.12, 13, 43, 61-62, 76, 80-182 The team then reviewed and summarized the twenty-nine topics relating to infant and toddler feeding addressed by the selected organizations, which are widely recognized for their pediatric nutrition expertise (Table 2). This review helped the Panel identify the topics to be included in the Start Healthy Feeding Guidelines.

For the topics to be included, recommendations and guidelines were evaluated for consistency among organizations. If the recommendations were consistent, then two main factors influenced the selection of topics for evidence analysis versus simply using the existing recommendations: 1) whether new information may be revealed in a certain area if an evidence-based approach were used, and 2) where practical advice was needed.

In certain areas, the existing recommendations were accepted as proposed by other organizations.12-79 These existing recommendations satisfactorily answer the questions found in Table 3.

Evaluate the Feeding and Nutrition Literature
As the core team examined existing recommendations for feeding, priority areas of focus emerged around which the Expert Panel developed research questions in reference to their relevance and importance to parents. One such area of focus, food transitions and developmental milestones, covers a broad range of feeding issues, from the initial introduction of solid foods into a previously all-milk or formula diet, to the gradual weaning to a varied diet, to the establishment of healthy eating habits that can last a lifetime. In order to examine the complex topic of food transitions, the Panel developed a framework with which to organize the research questions that included the topics of when, what, and how to feed infants and toddlers at each stage (Figure 1).

The question of when to feed infants and toddlers specific foods addressed the stages in oral readiness, gross and fine motor skill development, and gastrointestinal and renal maturation that must be achieved before a child can be introduced to each new food and texture. The question of what to feed addressed specific foods, nutrient requirements, and non-nutritional concerns such as food allergies and the role of physical activity for infants and toddlers. Introducing new foods and offering them a sufficient number of times, as well as the parent-child feeding relationship both factored into the question of how to feed. Figure 1 offers a quick reference of how each research question related to the broader questions parents might ask about when, what, and how to feed their child. The conclusion statements and grades for each of these questions can be found in the March 2004 issue of JADA.183

Evaluate the Nutrient Needs of Infants and Toddlers
The third methodology used to support the Guidelines' development included the evaluation of the nutrient needs of infants and toddlers. To answer the research question "what are the nutrient requirements of infants and toddlers?" the Expert Panel turned to the Dietary Reference Intakes (DRIs) from the Food and Nutrition Board, Institute of Medicine/Health Canada, which identify all the essential nutrients for healthy growth and development of infants and toddlers.28-31 Supplementing this information with biochemical or clinical evidence of nutrient deficiency among infants and toddlers helped the Panel identify which nutrients need to be especially emphasized to parents.

Infants present a special circumstance when determining the type and quantity of foods to feed, since a portion of their diet may consist of breast milk, for which specific intakes may be difficult to judge. To establish how much energy and nutrients infants require from the complementary foods they are fed, the Expert Panel subtracted the nutrients supplied by an average intake of human milk from recommended intake levels, which is comparable to methods employed by the WHO.184 The Panel determined how much energy infants 6 to 12 months old need from complementary foods by observing the difference between how much energy they might obtain from milk and their estimated energy requirements (EER) from the DRI. A similar process was used to determine which nutrients needed to be supplied by complementary foods. For children aged 6 to 24 months at the 50th percentile for weight from the CDC growth charts,14,185 the Panel calculated how much dietary energy is needed to support growth and a healthy energy balance.

To aid parents in making sure that their infants or toddlers receive all the nutrients they need, registered dietitians prepared sample menus specifically for each of the following age categories: infants 6 to 8 and 9 to 12 months of age, and toddlers 12 to 17 and 18 to 24 months of age. To analyze the nutrient content of these menus, the dietitians utilized software developed by the Nutrition Coordinating Center, University of Minnesota, Minneapolis.186 The menus created took into consideration the AAP's recommendations for the appropriate age and amounts to offer juice and whole cow's milk to children.12,187 The areas where it was vital to meet nutrient goals were identified, as were specific foods that may help meet these special nutrient needs. After assessing which nutrients are needed for healthy growth and development, it was clear to the Panel that high-calorie, low-nutrient foods, such as sweetened beverages and candy, have little or no place in an infant's or toddler's diet.

Converting the Data into Guidelines for Parents and Practitioners
With all of the articles and recommendations summarized and conclusion statements made, the Expert Panel set about forming the practical suggestions for parents, shaping their statements with regard to typical questions that parents might ask regarding feeding their infant or toddler, such as:

"When do I feed my baby?"
"What foods do I feed my baby?"
"How do I feed my baby?"

A near-term task is to determine the best way to make the messages of the Start Healthy Feeding Guidelines, such as the sample menus and developmental milestones and eating skills charts, available to both professionals and parents. Message testing with both parents and pediatric professionals will help to ensure that the materials are useful and being presented in the most helpful and practical way. All the components that make up the entire evidence analysis, from the initial worksheets to the conclusion statements, will surely become an important resource for researchers and practitioners.

The core team had important suggestions for groups that may elect to use an evidence-based approach in formulating guidelines for a specific population or group of people. These included the importance of training in evidence-based analysis for everyone involved in the process (not just the evidence analysts), and that a team should allow ample time to conduct literature searches, sort their findings, and discuss different facets of the process. Other suggestions included looking to additional experts for help and input, such as a librarian with an understanding of the topic at hand, and experts in fields not represented by the expert group conducting the evidence analysis. Finally, the team stressed the importance of ensuring consistency when completing worksheets and summaries through a system of checks and balances among the evidence analysts.

Conclusion
The team responsible for developing the Start Healthy Feeding Guidelines for Infants and Toddlers took great care to examine the topic of feeding recommendations from every angle, in order to generate practical guidance for both pediatric professionals and parents. Using the ADA's evidence-based review process allowed the team to mine the wisdom from scores of research and review articles and expert opinion statements to reach conclusions on the many different facets of feeding infants and toddlers. Supplementing this process with a review and synthesis of existing literature and a scientific analysis of nutritional needs resulted in a well-rounded, well-informed data set from which the Expert Panel drew the Guidelines, which can be found in the accompanying article in this journal.183 The process of evidence analysis also clearly identified areas where additional research is needed to truly address all the questions.

Examining the process followed to arrive at the Start Healthy Feeding Guidelines shows how careful methodology resulted in sound and practical suggestions for healthy feeding. Knowing that the Guidelines were developed using this rigorous process should assure pediatric health care providers that the information provided to consumers is truly the best advice available, based on the existing research.

Dr Esther Myers is Director, Scientific Affairs and Research at the American Dietetic Association. Among other research related activities she oversees the process used to analyze the evidence for evidence-based guides for Medical Nutrition Therapy that is provided by registered dietitians. She is an international speaker on the application of evidence-based practice.

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